HomeMy Public PortalAbout9944 DAINES DR_Mechanical__ • ll' WOrm the I have-ra cerci DECLARATION J APPLICATION FOR PERMIT
•"FliL�reby affirm that I have-a certificate of consent to'self � '
Insure, Sr a certificate of Workers',Compensation Insurance, 76A364C HEATING - VENTILATING - AIR CONDITIONING
or aacdrtified copy thereof (Sec 3800, Lab C )'
L_i • • CE-818(REV 10/81)
P❑014,.No- Company
Certified copy is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING `
tion department ADDRESS
(PRINT OR TYPE ONLY) y
Date Applicant LOCALITY l�
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST 1X5 G1 W tah
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO'- PROCESSED Y
the permit Is for one hundred dollars ($100)or less'.) \
I certify That In the performance of The work for, which this AIR HANDLING UNIT, CFM
permit Is Issued, I shall not employ any person In any manner
SO a5 t0 beCO a sublect to the Workers'Compensation Laws BOILER, BTU
APPROVALS DATE IN E TOR'S SIGNATURE
COMPRESSOR,-BTU ROUGH 14 A
f
Date pplicant (���
NOTI TO APPLICANT If, after making This Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER V LI ATION
with comply with such provisions or this permit shall be
deemed revoked ' FURNACE FAU X GR V TY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I HEATER hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED-UNIT-
(commencing
USPENDED UNIT ALL
(commencing with Section,7000) of Division 3 of the Business }
and Professions Code,and my license is in full force and effect '
License Number Llc Class ► U
OC
Contractor' Date �0
❑ I am exempt under Sec a
Plan check fee
B 8P C for this reason
Date o
PERMIT ISSUING FEE $ 5 ;28 0 ar1 A Z
Signature TOTAL FEE _ 5 # o o • o,e 8
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT • „� • , 3. 5,0
Thereby affirm that I am exempt from the Contractor's License ,
Law for the following reason (Section 7031 5, Business and NAME ^ 5 7J 5 0�
Professions Code) o e'•
'
I, as owner of the property; ADDRESS or my employees with V ;,I 0,07r87
wages as their sole compensation,will do the work and LL
the structure is not intended or offered for sale(Section CITY TEL NO V LIT17)
7044, Business and Professions Code) -
' OWNE
❑ 1, as owner of the property, a'm exclusively contracting
with licensed contractors to construct the project (Sec- MAIL
tion 7044, Business and Professions Code) ADDRESS CIQ 14 V N,, y�
CONSTRUCTION LENDING AGENCY CITY �� TEL NO2 (�-I-Z:)
I hereby affirm that there,is a construction lending agency for
the performance of,the work for which this permit is Issued CONTRACTOR
(Sec 3097, Civ C ) - -
ADDRESS
Lender's Name
CITY TEL NO.
Lender's Address
STATE LIC
I certify that I have read this application and state that the LICENSE NO CLASS
above Information is correct I agree To comply with all County
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter
( n thea ve-mentlnned p operty for Inspec ion p rposes SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent - '